Government agencies, like Centers for Medicare & Medicaid Services (CMS) and Office Of Inspector General (OIG), face unique challenges in terms of incorrect Medicare Advantage payments, conducting random and untargeted audits of prior payments, lack of capability to assess business impact due to policy changes to name a few.

HiLabs provides accelerating AI solutions which assist government agencies to-

• Identify billing issues around services that were never rendered or were more expensive (upcoding)
• Point out unnecessary medical services solely for the purpose of generating insurance payments.
• Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
• Provide holistic what-if-analysis capabilities in healthcare policy making involving average impact on RAF scores and associated dollar value, drill-down of the impact, impact analysis at beneficiary level etc.

With quickly changing environment caused due to rising costs, stricter mandates, digitalization, data privacy and security issues, Health plans are bleeding money, losing their market and are turning obsolete.

HiLabs provides accelerating solutions which assist Health plans at multiple fronts-

• Pin-point issues in provider directories
• Detecting errors in data migration, cleanup and testing
• Monitoring high cost claims pricing
• Proactively identifying risk adjustment opportunities
• Quality assurance of clinical data impacting measures like HEDIS, STARS
• Program integrity, detecting up-coding in Risk Adjustment and ER visits

To stay ahead in the Medicare and Medicare Advantage business, Health plans must ensure high quality care while also complying with the rapid change in government regulations

HiLabs provides accelerating solutions which assist plans to-

• Pin-point issues in provider directories
• Monitoring high cost claims pricing
• Proactively identifying risk adjustment opportunities

To stay ahead in the Medicaid business, Health plans must ensure high quality care while also complying with the rapid change in government regulations

HiLabs provides accelerating solutions which assist plans to-

• Pin-point issues in provider directories
• Monitoring high cost claims pricing
• Proactively identifying risk adjustment opportunities

An AI based pattern matching tool solves business problems related to-

• Provider In-Network Issues
• Provider Out of Network Issues
• Provider data migration testing
• Detecting data errors leading to lower HEDIS measures
• Proactive data quality monitoring in claims processing systems

A proactive approach to detect under-coding in Medicare Advantage data using a combination of Artificial Intelligence, Medical Ontologies, and Big Data. The tool has already found potential under-payment of $20M

The unguided AI solution detects up-coding in Medicare Advantage data and ER visits by performing comparative data quality and completeness of MA data. The tool has been customized on medical ontologies based learning to fine tune for Risk Adjustment. MSure has found potential overpayment of $80M in just one state (FL) and around $14M in ER visits for a large health plan in the first quarter of 2020

CMS often looks for capabilities in the Risk Adjustment Suite of Systems (RASS) system to do a what-if analysis. They aim to assess business impact on policy changes associated with the Risk Adjustment payments HiLabs’ MVision offers a configurable solution at various points in RASS processing which allows the business rules to change easily. The impact analysis related to the change can be performed by a business user in an easy to use web-based interface